Public Health Midterm

· What is a surveillance system?

- an information loop or cycle -starts and ends with communication and action -collection --> collation and recording (reporting) --> analysis and interpretation --> dissemination and utilization

Thalidomide

-teratogen

Core Functions of Public Health

1.Assessment 2.Policy Development 3.Assurance

Public Health Disciplines / Core Areas

1.Biostatistics 2.Environmental Health Science 3.Epidemiology 4.Health Policy and Management 5.Social and Behavioral Sciences

Public Health Approach

1.Define the health problem 2.Identify the risk factors associated with the problem 3.Develop and test community-level interventions to control or prevent the cause of the problem 4.Implement interventions to improve the health of the population. 5.Monitor the interventions to assess their effectiveness.

Non-governmental Public Health Organizations

American Cancer Society, American Heart Association, American Diabetes Association, Alzheimer's Disease and Related Disorders Association, and others American Medical Association, American Nurses Association, American Public Health Association, and others Consumer groups

· BRFSS

Behavioral Risk Factor Surveillance Survey (BRFSS) •The BRFSS objective is to collect uniform, state-specific data on preventive health practices and risk behaviors that are linked to chronic diseases, injuries, and preventable infectious diseases that affect the adult population. • •Some factors assessed by the BRFSS in 2017 include tobacco use, HIV/AIDS knowledge and prevention, exercise, immunization, health status, healthy days health-related quality of life, health care access, inadequate sleep, chronic health conditions, alcohol consumption, oral health, falls, drinking and driving, cancer screenings (including breast, cervical, prostate, colorectal cancers), and seatbelt use.

National Institutes of Health

Biomedical research agency Institutes on cancer, heart and lung disease, diabetes, aging, child health and human development, and others. National Library of Medicine Has laboratories in Bethesda, MD and provides grant funding to researchers in universities and research centers. Clinical Center where medical researchers test experimental therapies

Economic Impact

Businesses often resist public health measures because they affect profits Those who must pay may not be the ones who benefit Costs may be short-term, while benefits may be long-term Costs easier to calculate than benefits

· Case definition (also called surveillance definition)

Case definition (also called surveillance definition) •The clinical and laboratory characteristics that a patient must have to be counted as a case for surveillance purposes

Pharmacological treatments

Cholinesterase inhibitors: One way Alzheimer's disease harms the brain is by decreasing levels of a chemical messenger (acetylcholine) that's important for alertness, memory, thought and judgment. Cholinesterase (ko-lin-ES-tur-ays) inhibitors boost the amount of acetylcholine available to nerve cells by preventing its breakdown in the brain. Cholinesterase inhibitors can't reverse Alzheimer's disease or stop the destruction of nerve cells. These medications eventually lose effectiveness because dwindling brain cells produce less acetylcholine as the disease progresses. Common side effects can include nausea, vomiting and diarrhea. Starting treatment at a low dose and working up to a higher dose can help reduce side effects. Taking these medications with food also might help minimize side effects. People with certain types of cardiac arrhythmias shouldn't take cholinesterase inhibitors. Three cholinesterase inhibitors are commonly prescribed: Donepezil (Aricept) is approved to treat all stages of the disease. It's taken once a day as a pill. Galantamine (Razadyne) is approved to treat mild to moderate Alzheimer's. It's taken as a pill once a day or as an extended release capsule twice a day. Rivastigmine (Exelon) is approved for mild to moderate Alzheimer's disease. It's taken as a pill. A skin patch is available that can also be used to treat severe Alzheimer's disease. Memantine for later stages Memantine (Namenda) is approved by the FDA for treatment of moderate to severe Alzheimer's disease. It works by regulating the activity of glutamate, a messenger chemical widely involved in brain functions — including learning and memory. It's taken as a pill or syrup. Common side effects include dizziness, headache, confusion and agitation. The FDA has also approved a combination of donepezil and memantine (Namzaric), which is taken as a capsule. Side effects include headache, dizziness, nausea and diarrhea.

State Health Departments

Coordinate activities of local health agencies and provide funding Collect and analyze data Laboratory services Manage Medicaid License and certify medical personnel, facilities, and services Environment, mental health, social services, and aging may be handled by separate agencies

Core Functions of Public Health part 2

Core Function 1 - Assessment Collecting and analyzing information about health problems. Essential Service #1: Monitor health status to identify community health problems. Essential Service #2: Diagnose and investigate health problems and health hazards in the community. Core Function 2 - Policy Development Broad-based consultations with stakeholders to weigh available information and decide which interventions are most appropriate (relative to age and culture exc) and ensure that the public interest is served by measures that are adopted. Essential Service #3: Inform, educate, and empower people about health issues. Essential Service #4: Mobilize community partnerships to identify and solve health problems. Essential Service #5: Develop policies and plans that support individual and community health efforts. Core Function 3 - Assurance Promoting and protecting public interests through programs, events, campaigns, regulations and other strategies, and making sure that necessary services are provided to reach agreed upon goals. Essential Service #6: Enforce laws and regulations that protect health and ensure safety. Essential Service #7: Link people to needed personal health services and assure the provision of health care when otherwise unavailable. Essential Service #8: Assure a competent public health and personal healthcare workforce. Essential Service #9: Evaluate effectiveness, accessibility, and quality of personal and population-based health services. Essential Service #10: Research for new insights and innovative solutions to health problems.

Local Public Health Agencies

County and city health departments Day-to-day responsibility Core public health functions Often also have responsibility for providing medical care for the poor Funding sources are variable; city or county legislatures may not understand importance of core functions. Mandates may be funded from state or federal governments.

Sources of Controversy

Economic impact Individual liberty Moral and religious concerns Politics vs. science

· Compare and contrast the types of surveillance

Epidemiologic Sentinel -Monitoring of rate of occurrence of specific conditions to assess the stability or change in health levels of a population. - -It is also the study of disease rates in a specific cohort such as in a geographic area or population subgroup to estimate trends in a larger population. •Sentinel surveillance also requires more time and resources, but can often produce more detailed data on cases of illness because the health care workers have agreed to participate and may receive incentives. • •It may be the best type of surveillance if more intensive investigation of each case is necessary to collect the necessary data. • •For example, sentinel influenza surveillance in the United States collects nasopharyngeal swabs from each patient at selected sites to identify the type of influenza virus. Collection of such data from all health workers would not be possible. •

Pharmacological treatments

FDA-approved drugs - 2 types nCholinesterase inhibitors n nMemantine n They are: nAre approved for specific Alzheimer's stages. nAre not approved for MCI n The Food and Drug Administration (FDA) has approved two types of drugs specifically to treat symptoms of Alzheimer's disease. Cholinesterase inhibitors Memantine These drugs: Are approved for specific Alzheimer's stages. These stages — mild, moderate and severe — are based on scores on tests that assess memory, awareness of time and place, and thinking and reasoning. Doctors might, however, prescribe Alzheimer's drugs for stages other than those for which the FDA has approved them. Alzheimer's stages aren't exact, individual responses to drugs vary and treatment options are limited. If your doctor prescribes medication as part of your Alzheimer's care plan, make sure you understand the drug's potential benefits and risks for your situation. Are not approved for mild cognitive impairment (MCI). This condition, which involves subtle changes in memory and thinking, can be a transitional stage between normal age-related memory changes and Alzheimer's disease. Many people with MCI — but not all — eventually develop Alzheimer's or another dementia. Clinical trials testing whether Alzheimer's drugs might prevent progression of MCI to Alzheimer's have generally shown no lasting benefit.

IMR by race

In 2016, infant mortality rates by race and ethnicity were as follows: Non-Hispanic black: 11.4 American Indian/Alaska Native: 9.4 Native Hawaiian or other Pacific Islander: 7.4 Hispanic: 5.0 Non-Hispanic white: 4.9 Asian: 3.6

IMF in US compared to others

In 2017, the infant mortality rate in the United States was 5.8 deaths per 1,000 live births. The infant mortality rate is the number of deaths of infants under one year old per 1,000 live births. This rate is often used as an indicator of the level of health in a country. The infant mortality rate of the world is 49.4 according to the United Nations and 34.1 according to the CIA World Factbook. Note that due to differences in reporting, these numbers may not be comparable across countries. The WHO recommendation is that all children who show signs of life should be recorded as live births. In many countries this standard is not followed, artificially lowering their infant mortality rates relative to countries which follow those standards. (for data shown) U.S. infant mortality rates (deaths under one year of age per 1,000 live births) are about 71 percent higher than the comparable country average. Differential reporting methods are likely a factor: a recent paper from the American Economic Journal: Economic Policy found that data difference may explain up to 34 percent of the difference in infant mortality rates between the U.S. and comparable countries. -While differences in data collection may explain some of the difference in mortality rates, assuming that collection methods have not changed considerably overtime, the differences should not affect the relative rates of change overtime. From 2000 to 2014, the infant mortality rate in the U.S. improved by about 16 percent, while the comparable country average improved about 32 percent.

Centers for Disease Control and Prevention

Main epidemiologic and assessment agency for the nation Publishes Morbidity and Mortality Weekly Report (MMWR) Center for Health Statistics - collects data on U.S. population concerning all aspects of health Centers on infectious diseases, chronic disease, injury prevention, and others

Causes of IM

Over 23,000 infants died in the United States in 2016. The five leading causes of infant death in 2016 were: 1.Birth defects/congenital malformations. 2.Preterm birth / low birth weight. 3.Sudden infant death syndrome. 4.Maternal (pregnancy) complications. 5.(Unintentional) Injuries (e.g., suffocation). -The infant mortality rate (IMR)—the ratio of infant deaths to live births in a given year—is generally regarded as a good indicator of the overall health of a population. IMR changed from 587.0 infant deaths per 100,000 live births in 2016 to 579.3 in 2017, but this change was not statistically significant. In 2017, the infant mortality rate in the United States was 5.8 deaths per 1,000 live births. The 10 leading causes of infant death in 2017 accounted for 67.8% of all infant deaths in the United States. The leading causes remained the same as in 2016 although maternal complications became the third leading cause while sudden infant death syndrome became the fourth, and diseases of the circulatory system became the eighth leading cause while respiratory distress of newborn became the ninth (Figure 5). Causes of infant death are ranked according to number of infant deaths (1). IMR for unintentional injuries increased 10.7% from 30.9 infant deaths per 100,000 live births in 2016 to 34.2 in 2017. Mortality rates for other leading causes of infant death did not change significantly.

PKU

Phenylketonuria, also called PKU, is a rare inherited disorder that causes an amino acid called phenylalanine to build up in the body. PKU is caused by a defect in the gene that helps create the enzyme needed to break down phenylalanine. Without the enzyme necessary to process phenylalanine, a dangerous buildup can develop when a person with PKU eats foods that contain protein or eats aspartame, an artificial sweetener. www.mayoclinic.org/diseases-conditions/phenylketonuria/symptoms-causes/syc-20376302

Moral and Religious Opposition

Sex and reproduction Alcohol and drugs Assisted suicide and other end-of-life decisions - opposition for this because some religions think won't go to heaven

RUSP

The RUSP is a list of disorders that are recommended by the Secretary of the Department of Health and Human Services (HHS) for states to screen as part of their state universal newborn screening (NBS) programs. Disorders on the RUSP are chosen based on evidence that supports the potential net benefit of screening, the ability of states to screen for the disorder, and the availability of effective treatments. It is recommended that every newborn be screened for all disorders on the RUSP. Most states screen for the majority of disorders on the RUSP; newer conditions are still in process of adoption. Some states also screen for additional disorders. Although states ultimately determine what disorders their NBS program will screen for, the RUSP establishes a standardized list of disorders that have been supported by the Advisory Committee on Heritable Disorders in Newborns and Children and recommended by the Secretary of HHS. Conditions listed on the RUSP are part of the comprehensive preventive health guidelines supported by HRSA for infants and children under section 2713 of the Public Health Service Act. Non-grandfathered health plans are required to cover screenings included in the HRSA-supported comprehensive guidelines without charging a co-payment, co-insurance, or deductible for plan years beginning on or after the date that is one year from the Secretary's adoption of the condition for screening.

Social Justice vs. Market Justice

The common good Individual responsibility Questions about the scope of public health Importance of economic factors for health - politically controversial

Population Aged 65 and Over for the US in Millions: 2012-2015

The size and structure of the older population is important to public and private interests, both socially and economically. Between 2012 and 2050, the United States will experience considerable growth in its older population (see Figure 1).2 In 2050, the population aged 65 and over is projected to be 83.7 million, almost double its estimated population of 43.1 million in 2012. The baby boomers are largely responsible for this increase in the older population, as they began turning 65 in 2011.3 By 2050, the surviving baby boomers will be over the age of 85. MORTALITY: DRIVER OF TRENDS IN THE OLDER POPULATION The size and composition of the older population in 2050 will be largely determined by two fac- tors: the size and composition of the population 27 years and over in 2012 and the future course of mortality for that population. While past fertility rates were the main driver shaping the size of these cohorts to date, mortality will influ- ence the pace at which that popu- lation declines at the older ages. One important trend is the reduction in smoking. A lifetime of smoking greatly reduces old-age survival. In 1970, 45 percent of the population aged 25 to 44 smoked (this is the population aged 67 to 86 in 2012) (American Lung Association, 2011). In 2011, only 22.1 percent of those aged 25 to 44 smoked (this will be the population aged 64 to 83 in 2050) (Centers for Disease Control and Prevention, 2012). Reduction in smoking at younger ages is expected to improve survivorship for these cohorts when they reach the older ages. Minorities are not living as long as their white counterparts Women universally live longer than men nAn increase in the number of individuals with dementia and Alzheimer's Disease.

Politics vs. Science

There is always the possibility of tension Current conservative control of federal government intensifies the conflict Criticism of the Trump administration Prior administrations?

What is dementia

This term refers to a deterioration in mental capacities that goes beyond the normal age related changes in cognition. nDementia is an umbrella term used to describe a collection of symptoms that affect: -Memory, -Thinking and -Social abilities to the extent that they interfere with daily activities. Age-related memory changes may be related to slowed processing speed18, reduced ability to ignore irrelevant information19, and decreased use of strategies to improve learning and memory.20

When Can Government Restrict Individual Freedom?

To prevent harm to others - generally acceptable Paternalism - acceptable for children but not for adults To protect individuals from their own actions? (opposed by libertarians) For the "common good" - lots of room for controversy

Federal vs. State

U.S. Constitution: To promote the general welfare Reserve clause: since health is not mentioned in the Constitution, primary responsibility belongs to the states Interstate commerce clause justifies federal role in some cases Power to tax and spend is widely used by federal government to control public health policy

AD is Characterized by Deficits in Five Cognitive Domains:

n1. Memory n2. Language n3. Visuospatial Functioning nThe ability to perceive objects in space nAbility to: recognize shapes, retrace steps, find your way home or locate your car in a parking garage n4. Executive Functioning nAbility to plan, follow instructions, focus and problem solve n5. Attention

Risk Factors for Alzheimer's Disease

nAdvanced Age nFamily History nGenetics nParkinson's Disease nDown's Syndrome nHistory of Head Injury

Racial Disparities in Alzheimer's Disease Prevalence

nAfrican Americans and Hispanics are at a higher risk for developing Alzheimer's disease when compared to Whites. nAfrican Americans are twice as likely and Hispanics are 1.5 times more likely to develop Alzheimer's disease and other dementias. nA major consequence of this projected population growth will be the increased prevalence and incidence of Alzheimer's disease among older minorities, specifically African Americans nThe Alzheimer's Association labeled the disease a "silent epidemic among" African Americans (2003) n n And a major consequence of this projected population growth ...READ SLIDE •If no cure or preventative treatment is found In fact In 2003 the Alzheimer's Association labeled the disease a "silent epedemic" among African Americans Why has the disease reached epidemic proportions among African Americans? Well a number of risk factors for the disease are prevalent in the AA community like, Hypertension High Cholesterol Diabetes For one, African Americans have rates of hypertension that are among the worlds highest. And studies have shown that the risk of developing Alzheimer's disease is doubled in those with a history of high blood pressure or high cholesterol. Also, African Americans have a 60% higher risk of developing type 2 diabetes, a condition that contributes to the development of vascular dementia and Alzheimer's disease nAfrican Americans are less likely than Whites to receive a diagnosis of Alzheimer's disease although they are at an increase risk of developing the disorder. nAfrican Americans are also more likely to receive an initial diagnosis in the later stages of the disease when more cognitively and physically impaired. nA higher percentage of African Americans and Hispanics report not having been told by their doctor they have a "memory related disease". nGenetics nA strong link between the APOE e4 genetic allele and Alzheimer's disease has been established. nAlthough the APOE e4 allele is found to be higher in African Americans than Whites, the relationship to the development of Alzheimer's disease has been inconsistent and weak at best. nHowever, researchers have uncovered a strong relationship between a new gene, ABCA7 and Alzheimer's disease in African Americans nCardiovascular and Cerebrovascular Disease nVascular disparities are more prevalent among African Americans and Hispanics than Whites nHigh Blood Pressure and Diabetes have been shown to be significant risk factors for AD nHigh Blood Pressure is more common among African Americans and Diabetes is more common in Hispanics when compared to whites nStrokes and high cholesterol are more prevalent among African Americans which put them at a greater risk for Alzheimer's Disease nYears of Education nAfrican American and Hispanic minorities, on average, have lower levels of education when compared to Whites nLower levels of education has been associated with an increased risk for Alzheimer's nCultural Factors nMemory loss often perceived among minorities as a normal part of aging nStigma of the disease results in a later diagnosis Service use nA result of being more impaired both physically and cognitively is a substantially increased use of health services among minorities with Alzheimer's disease.

Common Causes or Subtypes of Dementia

nAlzheimer's Disease nVascular Dementia nLewy Body Dementia nParkinson's Disease nHuntington's Disease nFrontotemporal Dementia nComplications from the HIV Infection

All-Cause Dementia Diagnosis

nDiagnosis encompasses a range of symptoms ranging from mild to severe to include: nAn inability to function at work or during usual activities nA decline in one's previous level of functioning nChanges not explained by delirium or a mental illness nA diagnosis of cognitive impairment through a combination of: nA detailed account of changes from the patient or an informant nNeuropsychological testing nImpairment in two or more of the following domains: nAn inability to remember new information nImpaired reasoning and inability to handle complex tasks nImpaired visuospatial abilities n"Parked car in relation to store" nImpaired language functions n"We went to that place to pick up some bread" nChanges in personality and behavior

Barriers to Participation to Clinical Research Participation

nLack of Awareness about Research Studies nFear nExperimentation ("Guinea Pig") nSide-Effects nDistrust of Formal Institutions nPast Historical Occurrences (previously discussed) nTuskegee Syphilis Study nHenrietta Lacks Legacy of Tuskegee Study is that African Americans are more distrustful of researchers in general and fearful about taking new drugs and participating in clinical trials....

AD Early Signs & Symptoms

nMemory loss that disrupts daily life nChallenges in planning and solving problems nDifficulty completing familiar tasks nConfusion with time or place nDifficulty understanding visual images and spatial relationships nProblems with vocabulary and conversations nForgetfulness and a decreased ability to retrace one's steps nDecrease or poor judgement nWithdrawal from work or social activities nChanges in mood and personality

Disparities in Clinical Research Participation

nMinority patients are underrepresented in clinical trials. nAlthough minorities account for about 1/3 of all Americans, less than one-tenth of U.S. clinical trial participants are minorities. n nLess than 5% of clinical trial participants are African American n nLack of minority participation raises concerns about the benefits and effectiveness of treatments among African Americans nLess than 5% of clinical trial participants are African American n nLack of minority participation raises concerns about the benefits and effectiveness of treatments among African Americans There is a desperate need to develop new medicines for diseases that disproportionately affect African Americans..like, cancer, heart disease, hypertension, diabetes and Alzheimer's. There is a growing body of evidence that minority and ethnic populations respond differently to certain medications _____________________________________________________________ For example, African Americans with high blood pressure typically respond to diuretics much better than whites, and Asians respond to some anti-psychotic drugs at a dosage of one-tenth that required for whites. Some studies have shown differences in the physiological response of African Americans compared to whites... Responses to vasodialators in the treatment of hypertension may differ between African Americans and whites.... In fact, in 2005 the Food and Drug Administration for the first time approved a drug specifically intended for use by African Americans with congestive heart failure, who responded less effectively to available medicines.

Benefits to an Early Diagnosis of Alzheimer's Disease

nPharmacological treatments nEarly or Mild Stage of AD nPatient nAdvanced Planning nCaregiver nSocial Support Network nFamiliarize themselves with Formal Services When diagnosis of Alzheimer's disease occurs in the early or mild stage of the disease , More time is available for pharmacological treatments that can help slow down the progression of the disease The patient is able to assume an active role in the planning of their care By making their desires known to family members and their clinicians And the Caregiver is able to Mobilize their social support network and Familiarize themselves with formal support services

Race is a Less Understood Variable

nPhysicians are becoming more uncomfortable with making treatment decisions based on all-white male data. nThere is mounting evidence of racial differences: nRate of drug metabolism nPharmacologic response nUnderlying disease mechanisms

Significant differences in AD exist across racial and ethnic groups in:

nPrevalence nIncidence nTreatment nClinical Trial Participation nUse of Services nDisease Related Cost nMortality

Disparities in AD Treatment Access and Options

nPrior studies reveal that African Americans are far less likely to be referred to a geriatric specialist or neurologist for diagnostic or treatment options when compared to older whites. nA lack of health insurance and financial resources among older African Americans may contribute to the underutilization of specialty services and necessitate the need for formal care.

Alzheimer's Disease (AD)

nThe most common type of dementia nSixth leading cause of death in the US of which cannot be prevented, cured or slowed.. n2/3 of individuals with AD are women nThe disease will cost the nation an estimated $226 Billion in 2015 and $1.1 Trillion by 2050. nMost common cause of dementia in people aged 65 older. nThe vast majority of AD cases are "late onset" occurring in individuals aged 65 and older. n

Why is this issue important?

nUnder-representation or a limited number of minorities in clinical research jeopardizes the generalizability of the study results. n

How can consumers be sure a genetic test is valid and useful?

• •Before undergoing genetic testing, it is important to be sure that the test is valid and useful. • •A genetic test is valid if it provides an accurate result. • •Accuracy measures for genetic tests -analytical validity -clinical validity - •Quality measure of a genetic test is its usefulness -clinical utility Analytical validity -how well the test predicts the presence / absence of a particular gene / genetic change. -Can the test accurately detect whether a specific genetic variant is present / absent? Clinical validity -how well the genetic variant being analyzed is related to the presence, absence, or risk of a specific disease. Clinical utility -whether the test can provide information about diagnosis, treatment, management, or prevention of a disease that will be helpful to a consumer. •

SIDS

•"Back to Sleep" campaign •SIDS rate has fallen by over 50%

genetic testing

•A genetic test examines the DNA (deoxyribonucleic acid) of a person's cells. Genetic testing can identify changes in genes or can analyze the number, arrangement, and characteristics of the chromosomes. • •Testing may be performed on samples of blood, semen, urine, saliva, stool, body tissues, bone, or hair. •A genetic test examines the DNA (deoxyribonucleic acid) of a person's cells. Genetic testing can identify changes in genes or can analyze the number, arrangement, and characteristics of the chromosomes. • •Testing may be performed on samples of blood, semen, urine, saliva, stool, body tissues, bone, or hair.

· Notifiable disease (do not need to know all of the notifiable diseases in VA - top 3 from each category)

•A notifiable disease is any disease that is required by law to be reported to government authorities. The collation of information allows the authorities to monitor the disease, and provides early warning of possible outbreaks.

· Sentinel site

•A sentinel site is a community from which in-depth data are gathered and the resulting analysis is used to inform programs and policies affecting a larger geographic area.

Family Planning and Adolescent Pregnancy

•Adolescent pregnancy has physical and social risks for mother and child •Planned pregnancy leads to healthier outcomes •Controversy about government provision of family planning services •Sex education in schools is still controversial -Federal requirement for abstinence only programs -Abstinence only education is less effective • •

Social and Behavioral Sciences

•Behavior is now the leading factor in affecting people's health •Theories of health behavior: social environment affects people's behavior •Major health threats: (1) tobacco, (2) poor diet and physical inactivity, injuries •Maternal and child health - a social issue

Ted Slavin

•Born a hemophiliac • •Exposed to hepatitis B virus and later blood tests show extremely high concentrations of hepatitis B antibodies • •Doctor informs Ted of the blood test and his blood's potential value • • Ted sells blood to pharmaceutical companies and partners with others to form a company • •Uncovers link between Hepatitis B and liver cancer and creates first hepatitis B vaccine

Genetic Diseases

•Chromosomal abnormalities - e.g., Down syndrome •Mendelian genetics -Autosomal dominant -Autosomal recessive -X-linked •May be caused by new mutations •Severity of some genetic conditions may be affected by environment -- e.g. anencephaly and spina bifida -Folic acid supplements can reduce risk •Genes influence susceptibility to diseases of adulthood •

Biostatistics

•Collection of data on the population •These numbers are diagnostic tools for the health of the community •The science of statistics is used to calculate risks, benefits.

Prenatal diagnosis

•Considerations •Down syndrome •Anencephaly and spina bifida

Privacy and Confidentiality

•DNA banking by governments - use for criminal justice, identification, health policy -http://wtvr.com/2015/02/02/dna-database-expansion/ - • •GINA - Genetic Information Nondiscrimination Act (May 2008) -forbids insurance companies from discriminating through reduced coverage or pricing and prohibits employers from making adverse employment decisions based on a person's genetic code. In addition, insurers and employers are not allowed under the law to request or demand a genetic test. •Newborn Screening -State laws (mandatory for various tests in most states) -Cost (who pays?) -Respect of human rights •Mandatory tests not consistent with human rights • Screening benefits the individual not necessarily society (no imminent harm to others) http://www.thehastingscenter.org/pdf/hcr_2008_may_jun_early_release1.pdf?src=bailymurraypdf -

· What is epidemiologic surveillance?

•Epidemiologic surveillance is the ongoing systematic collection, recording, analysis, interpretation, and dissemination of data reflecting the current health status of a community or population. • •The scope of epidemiologic surveillance has evolved from an initial focus on infectious disease monitoring and intervention to a more inclusive scope that includes chronic diseases, injuries, environmental exposures, and social factors that influence health status. • •Surveillance is based on both passive and active data collection processes.

Public Health and Terrorism

•Events of 9/11 and the anthrax letters highlighted the importance of public health. •The public health response to disasters, both natural and man-made, helps to control the damage and prevent further harm to survivors and rescuers (Hurricane Harvey, 2017; California Landslides/Wildfires, 2018). •Bioterrorism is recognized primarily through classical public health measures similar to those used in natural epidemics.

Importance of Infant and Child Health

•Foundation of health throughout life •Children are most vulnerable group in society •Infant mortality rate (IMR) is an indicator of health status of population •IMR higher for blacks than whites - indicator of health disparity -Infant mortality rate (IMR) is more than a marker of maternal and child health; it is a symbolic benchmark of a society's overall health. By this standard, the United States is deficient with the following 2 striking characteristics: its IMR is high compared with other developed nations, and African-American infants have a 2.2-fold greater mortality rate than white infants.

Preventing Birth Defects

•Genetic and newborn screening •FDA regulation of teratogenic drugs (i.e. Accutane, Thalidomide) •Warnings against alcohol for pregnant women (fetal alcohol syndrome) •Immunization of all children against rubella protects infants •Dietary supplementation with folic acid (neural tube defects) •

Genetic vs. Genomic Testing

•Genetic tests focus on an individual's inheritance of a single gene, while genomic tests (such as genetic panels or exome/whole genome sequencing) look at an individual's wider inheritance of various genetic traits. • •Most tests are not regulated As the field of genomics advances, genetic and genomic tests are becoming more common in, and out of, the clinic. Yet most genetic tests today are not regulated, meaning that they go to market without any independent analysis to verify the claims of the seller. The landscape is evolving, however, and it is likely that more of the genetic and genomic testing industry will face greater oversight in the future.

John Moore

•Hairy-cell leukemia that filled spleen with cancer cells •Referred to cancer researcher, David Golde •Signed consent to have spleen removed and discarded by hospital •Follow up appointments for samples for 7 years • •Who Told You You Could Sell My Spleen?" (Chapter 25 - from The Immortal Life of Henrietta Lacks" •Grew suspicious when asked to sign a consent form: -I (do do not) voluntarily grant to the University of California all rights I, or my heirs, may have in any cell line or any other potential product which might be developed from the blood and/or bone marrow obtained from me - •Mo cell line and commercial interests showed contracts valuing ~$3.5 million with estimated market value at ~$3 billion •Couldn't sell his own cells because it violated Golde's patent • •Sued and seven years later (1990) final ruling by California Supreme Court (upheld by U.S. Supreme Court) ruled that tissues removed with or without consent during treatment are considered waste but did cite the lack of informed consent. • •Golde died in 2004 of suicide •

Environmental Health Science

•Health effects of environmental exposures •Air Quality •Water Quality •Solid and hazardous wastes •Safe food and drugs •Global environmental change

Epidemiology

•Health effects of environmental exposures •Air Quality •Water Quality •Solid and hazardous wastes •Safe food and drugs •Global environmental change

Henrietta Lacks

•Her name was Henrietta Lacks, but scientists know her as HeLa. • •She was a poor black tobacco farmer whose cells—taken without her knowledge in 1951—became one of the most important tools in medicine, vital for developing the polio vaccine, cloning, gene mapping, in vitro fertilization, and more.

genomic medicine

•Human Genome Project •Many potential benefits •Many dilemmas •Cancer genes: e.g. BRCA1 and BRCA2 •Targeted therapies -

Children's Health and Safety

•Immunizations required before entering school - what are we seeing now? -Herd immunity •Public health efforts to vaccinate younger children •CDC tracks immunization rates •Well baby care and screenings in school •Childhood asthma is growing -•Fluoridation of water to prevent tooth decay •Regulation of day care centers - why? •U.S. Consumer Products Safety Commission regulates toys and children's furniture •Public health campaigns for child safety seats, bicycle helmets •Governments also provide diagnostic, treatment, and rehabilitative services for children with special needs

Reasons for IMR decline in US

•Improved SES, housing and nutrition •Immunization •Clean water and pasteurized milk •Antibiotics •Better prenatal care and delivery •Availability of family planning services and legalized abortion -Because wanted babies are more likely to thrive than unwanted ones; recent improved technological advances for premies and infants with low birth weights decreased IMR

SUIDS

•In 2015, sudden unexpected infant death (SUID) accounted for just over 15% of all infant deaths in the United States. •SUID - sudden, unexpected death of an infant < 1 year old w/o an obvious cause of death before investigation (3 types). -SIDS -Unknown causes -Accidental suffocation/strangulation in bed -Most SUIDs are reported as one of three types: sudden infant death syndrome (SIDS), unknown causes, or accidental suffocation and strangulation in bed. CDC's Division of Reproductive Health has SUID monitoring programs in 16 states and 2 jurisdictions, covering about 30% of all SUID cases in the United States. Participating states and jurisdictions use data about SUID trends and circumstances to develop strategies to reduce future deaths.

Public Health vs. Medical Care

•In medicine the patient is the individual; in public health, the patient is the community •Public health diagnoses the health of the community using public health sciences •Treatment of the community involves new policies and interventions •Goal of medicine is cure; goal of public health is prevention of disease and disability

IMR Health Problem v. Social Problem

•Infant mortality is not a health problem •It is a social problem with health consequences •

Infant Mortality

•Infant mortality is the death of an infant before his or her first birthday. •The infant mortality rate is the number of infant deaths for every 1,000 live births. •In addition to giving us key information about maternal and infant health, the infant mortality rate is an important marker of the overall health of a society.

Environmental Teratogens

•Infectious pathogens - syphilis, rubella, toxoplasmosis •Environmental chemicals - e.g., mercury •Drugs - e.g., thalidomide, Accutane, hormones •Alcohol

genetic testing

•Information on various traits and characteristics • •Screen for future/potential health risks • •Predict how you'll respond to medication (pharmacogenetics) • •Information on ancestry • •Forensics ••As of April 4, 2016 •79,003 Tests •4,548 Disorders •5,386 Genes •680 Laboratories •1,067 Clinics (www.genetests.org) ••Potential Tests • -Alpha-1-antitrypsin deficiency (AAT; emphysema and liver disease) -Amyotrophic lateral sclerosis (ALS; Lou Gehrig's Disease; progressive motor function loss leading to paralysis and death) -Alzheimer's disease* (APOE; late-onset variety of senile dementia) -Ataxia telangiectasia (AT; progressive brain disorder resulting in loss of muscle control and cancers) -Gaucher disease (GD; enlarged liver and spleen, bone degeneration) -Inherited breast and ovarian cancer* (BRCA 1 and 2; early-onset tumors of breasts and ovaries) -- -Hereditary nonpolyposis colon cancer* (CA; early-onset tumors of colon and sometimes other organs) -Charcot-Marie-Tooth (CMT; loss of feeling in ends of limbs) -Congenital adrenal hyperplasia (CAH; hormone deficiency; ambiguous genitalia and male pseudohermaphroditism) -Cystic fibrosis (CF; disease of lung and pancreas resulting in thick mucous accumulations and chronic infections) -Duchenne muscular dystrophy/Becker muscular dystrophy (DMD; severe to mild muscle wasting, deterioration, weakness) -Dystonia (DYT; muscle rigidity, repetitive twisting movements) -Fanconi anemia, group C (FA; anemia, leukemia, skeletal deformities) -Factor V-Leiden (FVL; blood-clotting disorder) -Fragile X syndrome (FRAX; leading cause of inherited mental retardation) -Hemophilia A and B (HEMA and HEMB; bleeding disorders) •- -Hereditary Hemochromatosis (HFE; excess iron storage disorder) -Huntington's disease (HD; usually midlife onset; progressive, lethal, degenerative neurological disease) -Myotonic dystrophy (MD; progressive muscle weakness; most common form of adult muscular dystrophy) -Neurofibromatosis type 1 (NF1; multiple benign nervous system tumors that can be disfiguring; cancers) -Phenylketonuria (PKU; progressive mental retardation due to missing enzyme; correctable by diet) -Adult Polycystic Kidney Disease (APKD; kidney failure and liver disease) -Prader Willi/Angelman syndromes (PW/A; decreased motor skills, cognitive impairment, early death) -Sickle cell disease (SS; blood cell disorder; chronic pain and infections) -Spinocerebellar ataxia, type 1 (SCA1; involuntary muscle movements, reflex disorders, explosive speech) -Spinal muscular atrophy (SMA; severe, usually lethal progressive muscle-wasting disorder in children) -Thalassemias (THAL; anemias - reduced red blood cell levels) -Tay-Sachs Disease (TS; fatal neurological disease of early childhood; seizures, paralysis) [3/99] ••Types/timing of testing • -carrier screening, which involves identifying unaffected individuals who carry one copy of a gene for a disease that requires two copies for the disease to be expressed -preimplantation genetic diagnosis - -prenatal diagnostic testing ••Types/timing of testing: • -newborn screening -presymptomatic testing for predicting adult-onset disorders such as Huntington's disease -presymptomatic testing for estimating the risk of developing adult-onset cancers and Alzheimer's disease -confirmational diagnosis of a symptomatic individual -forensic/identity testing/parental - -pharmacogenetics Newborn screening is a public health program of screening in infants shortly after birth for a list of conditions that are treatable, but not clinically evident in the newborn period. Some of the conditions included in newborn screening programs are only detectable after irreversible damage has been done; in some cases sudden death is the first manifestation of a disease. Screening programs are often run by state or national governing bodies with the goal of screening all infants born in the jurisdiction. The number of diseases screened for is set by each jurisdiction, and can vary greatly. Most newborn screening tests are done by measuring metabolites and enzyme activity in whole blood samples collected on specialized filter paper. Many areas are starting to screen infants for hearing loss using automated auditory brainstem response and congenital heart defects using pulse oximetry. Infants who screen positive undergo further testing to determine if they are truly affected with a disease or if the test result was a false positive. Follow-up testing is typically coordinated between geneticists and the infant's pediatrician or primary care physician. Newborn screening debuted as a public health program in the United States in the early 1960s, and has expanded to countries around the world, with different testing menus in each country. Both prenatal screening (screening before birth) and newborn screening (screening soon after birth) have improved health care. The first disorder detected by modern newborn screening programs was phenylketonuria, a metabolic condition in which the inability to degrade the essential amino acid phenylalanine can cause irreversible mental retardation unless detected early. With early detection and dietary management, the negative effects of the disease can be largely eliminated. Robert Guthrie developed a simple method using a bacterial inhibition assay that could detect high levels of phenylalanine in blood shortly after a baby was born. Guthrie also pioneered the collection of blood on filter paper which could be easily transported, recognizing the need for a simple system if the screening was going to be done on a large scale. Newborn screening around the world is still done using similar filter paper.

Newborn Screening

•Newborn screening is a public health program designed to screen infants shortly after birth for a list of conditions that are treatable, but not clinically evident in the newborn period. • •Some of the conditions included in newborn screening programs are only detectable after irreversible damage has been done, in some cases sudden death is the first manifestation of the disease.

Guidelines for Genetic Screening

•Newborn screening only when benefits the newborn, when can confirm diagnosis and when treatment and follow-up are available for infants • • •Carrier identification should be voluntary and confidential and include counseling Screening•Prenatal diagnosis should be include education and counseling • •All tests of high quality, evaluated by FDA; government oversight of laboratory proficiency • •More education for the general public about genetics •

Social Factors in Infant Mortality

•Number one risk factor is poverty •Reasons why low SES increases risk -Environmental hazards -Poor nutrition -Maternal risk behaviors - smoking, alcohol, illegal drugs -Social factors - young maternal age, violence, stress, lack of social support -Lack of prenatal care

IMR-US

•Over the past decade, the overall infant mortality rate in the United States has improved, declining from 6.86 infant deaths per 1,000 live births in 2005—a recent high—to 5.9 in 2016. •In 2017, the infant mortality rate in the United States was 5.8 deaths per 1,000 live births. -you do need to know where the heaviest concentrations are i.e. south, etc.) -¹The number of infant deaths per 1,000 live births. Healthy People provides science-based, 10-year national objectives for improving the health of all Americans. One of the Healthy People 2020 objectives is to reduce the rate of all infant deaths. In 2016, 23 states met the Healthy People 2020 target of 6.0 infant deaths per 1,000 live births. Geographically, infant mortality rates in 2016 were highest among states in the south. Rates were also high in some states in the Midwest

· Passive v. active surveillance

•Passive surveillance -It is the routine reporting of the cases of diseases reaching health care facilities for treatment or service. No special effort is made to find unsuspected disease incidents. •Active surveillance -An active surveillance system provides stimulus to health care workers in the form of individual feedback or other incentives. Often reporting frequency by individual health workers is monitored; health workers who consistently fail to report or complete the forms incorrectly are provided specific feedback to improve their performance. There may also be incentives provided for complete reporting. •Active surveillance requires substantially more time and resources and is therefore less commonly used in emergencies. • •It is often more complete than passive surveillance. • •It is often used if an outbreak has begun or is suspected to keep close track of the number of cases. • •Community health workers may be asked to do active case finding in the community in order to detect those patients who may not come to health facilities for treatment. •

Preventing Low Birth Weight

•Prenatal care •Reducing adolescent pregnancy •Causes of low birth weight are not well understood •Recent increases in low birth weight due to multiple births because of reproductive technology •

Public Health: Prevention and Intervention

•Primary prevention - stop disease form occuring before it happens (vaccination) •Secondary prevention - treat disease early (acess to plan b) •Tertiary prevention - seek to lessen the impat of diseae on patient function, longevity and quality of life (emergency response time)

Prenatal Care

•Provides women with information •Diagnose problems early •Can often link poor women with social services (WIC/SNAP) •Most states try to remove financial barriers •States and federal government collect data on prenatal care

Health Policy and Management

•Role of medical care in public health •Cost of medical care in U.S. is out of control •U.S. has a high percentage of population without health insurance - these people often lack access to medical care •Quality of medical care can be measured, and is often questionable. •

Public Health: Science and Politics

•Science is how we understand threats to health, determine what interventions might work, and evaluate whether the interventions worked •Politics is how we as a society make decisions about what policies to implement

carrier screening

•Screen for recessive genes in high-risk populations •Tay-Sachs disease among those of Jewish decent -Encouraged by Jewish leaders •Sickle cell disease among African Americans -Screening program in 1970s was misunderstood and poorly conducted •

Kinds of Contraception

•Sterilization - common method, but permanent •Oral contraceptives and other hormones •IUDs •Barrier methods - condom, diaphragm, cervical cap -Prevents sexually transmitted disease -Used inconsistently and unreliably •Plan B - now widely available, although controversial (THIS SHOULD NOT BE USED AS A PRIMARY METHOD OF BIRTH CONTROL)

· Cancer Surveillance - SEER (do not need to know all of the states that have it - does Virginia have it?)

•Surveillance, Epidemiology, and End Results (SEER) •The SEER Program provides information on cancer statistics to help reduce the cancer burden among the U.S. population. • •SEER has been funded by the NCI since 1973. -•SEER -- cancer incidence and survival data from population-based cancer registries • •Covers approximately 34 percent of the U.S. population. • •SEER registries -- collect data on patient demographics, primary tumor site, tumor morphology and stage at diagnosis, first course of treatment, and follow-up for vital status (survival). • •Data collected on every cancer case reported from 19 U.S. geographic areas. -SEER collects and publishes cancer incidence and survival data from population-based cancer registries covering approximately 34 percent of the U.S. population. These registries routinely collect data on patient demographics, primary tumor site, tumor morphology and stage at diagnosis, first course of treatment, and follow-up for vital status (survival). These data are collected on every cancer case reported from 19 U.S. geographic areas. -•12 states with central cancer registries -Connecticut, Hawaii, Iowa, Kentucky, Louisiana, New York, New Mexico, Utah, Idaho, Massachusetts, Wisconsin, and Georgia •4 metropolitan, multi-county areas with regional registries -(Greater California; Greater Bay, comprised of San Francisco-Oakland and San JoseMonterey; Los Angeles; and Seattle-Puget Sound) •New Mexico registry -Alaska Natives, Arizona Indians, and Cherokee Nation (Oklahoma) • •Areas representative of the demographics of the entire U.S. population. • •Broad coverage allows SEER to account for diverse populations throughout the U.S., including 31.9% of whites, 30.0% of blacks, 44.0% of Hispanics, 49.3% of American Indian/Alaska Natives, 57.5% of Asians, and 68.5% of Native Hawaiian/Pacific Islanders. -These areas are representative of the demographics of the entire U.S. population. This broad coverage allows SEER to account for diverse populations throughout the U.S., including 31.9% of whites, 30.0% of blacks, 44.0% of Hispanics, 49.3% of American Indian/Alaska Natives, 57.5% of Asians, and 68.5% of Native Hawaiian/Pacific Islanders. •Evaluate cancer prevention and screening programs and the quality of cancer care • •Document disparities by race/ethnicity, gender, geography, and other variables • •Demonstrate the effectiveness of public health interventions • •Guide the translation of research into health policy and practice

newborn screening

•Test drop of blood from newborns for metabolic abnormalities •All newborns in US are screened for at least two conditions: PKU and congenital hypothyroidism •States vary in conditions screened for •Most conditions are autosomal recessive metabolic disorders •Early diagnosis can prevent or reduce permanent damage •Some conditions are complicated to test for: e.g. cystic fibrosis • •

Are data comparable?

•The IMR of the world is 49.4 according to the United Nations and 34.1 according to the CIA World Factbook. •Note that due to differences in reporting, these numbers may not be comparable across countries. •The WHO recommendation is that all children who show signs of life should be recorded as live births. •In many countries this standard is not followed, artificially lowering their infant mortality rates relative to countries which follow those standards. •Nonetheless, the IMR for the US is higher than many other industrialized countries

· Public-Use Data Files (purpose)

•The National Center for Health Statistics (NCHS) offers downloadable public-use data files through the Centers for Disease Control and Prevention's (CDC) FTP file server. • •Users of this service have access to data sets, documentation, and questionnaires from NCHS surveys and data collection systems. Downloading instructions are available in "readme" files.

Recommended Uniform Screening Panel (RUSP)

•The RUSP - list of disorders recommended by the Secretary of the DHHS for states to screen as part of their state's universal NBS programs. • •Disorders chosen based on the 1) potential net benefit of screening, 2) the ability of states to screen for the disorder, and 3) the availability of effective treatments. • •Recommended that every newborn be screened for all disorders on the RUSP - left up to the states - some states screen for more

Virginia Newborn screening program

•The Virginia Newborn Screening Program is composed of several service-programs including -Dried Blood Spot Testing - -Critical Congenital Heart Disease - -Early Hearing Detection and Intervention, and - -VaCARES Birth Defects Surveillance.

What is Public Health?

•The fulfillment of society's interest in assuring the conditions in which people can be healthy. •Organized community efforts aimed at the prevention of disease and the promotion of health. •Health Promotion, Disease Prevention -Health promotion and disease prevention programs focus on keeping people healthy. Health promotion programs aim to engage and empower individuals and communities to choose healthy behaviors, and make changes that reduce the risk of developing chronic diseases and other morbidities.

Who owns the products of genetic information?

•The individual researcher •The institution with whom they are affiliated •Funding organization •Individual(s) from whom genetic material was obtained •Patent types: -Product -Process -Use - •Gene sequence •Protein product •Method of detection, production, or manipulation of the gene/protein ••PROS: -promotes investment -rewards routine discovery -Protects inventions without secrecy -Wasteful duplication of effort is prevented. -Research is forced into new, unexplored areas • •CONS: -discourages innovation. -prevents or hinders development of new or improved medicines and treatments (secrecy issues) -limits access to healthcare by increasing the cost of diagnostic [tests] and treatment for certain diseases -exploits information and materials and inhibiting their free exchange between researchers -extensive and costly legal battles. -Partial patents can penalize those discovering biological function/application -Patenting a part of nature - one organism owns a part or all of another organism -Patenting before or instead of publishing - -A gene patent is the exclusive rights to a specific sequence of DNA (a gene) given by a government to the individual, organization, or corporation who claims to have first identified the gene. Once granted a gene patent, the holder of the patent dictates how the gene can be used, in both commercial settings, such as clinical genetic testing, and in noncommercial settings, including research, for 20 years from the date of the patent. Gene patents have often resulted in companies having sole ownership of genetic testing for patented genes. On June 13, 2013, in the case of the Association for Molecular Pathology v. Myriad Genetics, Inc., the Supreme Court of the United States ruled that human genes cannot be patented in the U.S. because DNA is a "product of nature." The Court decided that because nothing new is created when discovering a gene, there is no intellectual property to protect, so patents cannot be granted. Prior to this ruling, more than 4,300 human genes were patented. The Supreme Court's decision invalidated those gene patents, making the genes accessible for research and for commercial genetic testing. The Supreme Court's ruling did allow that DNA manipulated in a lab is eligible to be patented because DNA sequences altered by humans are not found in nature. The Court specifically mentioned the ability to patent a type of DNA known as complementary DNA (cDNA). This synthetic DNA is produced from the molecule that serves as the instructions for making proteins (called messenger RNA). •In general, raw products of nature are not patentable. DNA products usually become patentable when they have been isolated, purified, or modified to produce a unique form not found in nature. • •Genetic information has been since the 1980's -1980 Diamond v. Chakrabarty • •Currently over three million genome-related patent applications have been filed. •On June 13, 2013, in the case of the Association for Molecular Pathology v. Myriad Genetics, Inc., the Supreme Court of the United States ruled that human genes cannot be patented in the U.S. because DNA is a "product of nature." • •The Court decided that because nothing new is created when discovering a gene, there is no intellectual property to protect, so patents cannot be granted. Prior to this ruling, more than 4,300 human genes were patented. The Supreme Court's decision invalidated those gene patents, making the genes accessible for research and for commercial genetic testing. https://www.supremecourt.gov/opinions/12pdf/12-398_1b7d.pdf

· Purpose of NNDSS

•To protect Americans from serious disease, NNDSS helps PH monitor, control, and prevent about 120 diseases. •These diseases are important to monitor nationwide -include infectious diseases i.e. •Zika •foodborne outbreaks such as E. coli, and •noninfectious conditions such as lead poisoning. •To protect Americans from serious disease, the National Notifiable Diseases Surveillance System (NNDSS) helps public health monitor, control, and prevent about 120 diseases. These diseases are important to monitor nationwide and include infectious diseases such as Zika, foodborne outbreaks such as E. coli, and noninfectious conditions such as lead poisoning. About 3,000 public health departments gather and use data on these diseases to protect their local communities. Through NNDSS, CDC receives and uses these data to keep people healthy and defend America from health threats. NNDSS is a multifaceted program that includes the surveillance system for collection, analysis, and sharing of health data. It also includes policies, laws, electronic messaging standards, people, partners, information systems, processes, and resources at the local, state, territorial, and national levels.

Genetic Problems - Chromosomal

•Trisomy - 3 copies of chromosome -Down's Syndrome •(trisomy 21) -Trisomy 13 (Patau) • •Monosomy - 1 copy (missing one) •Turner syndrome is a genetic condition caused by an abnormality on one of your sex chromosomes. It's also called monosomy X, gonadal dysgenesis, and Bonnevie-Ullrich syndrome. The condition is found only in the female gender. Turner syndrome occurs when part or all of one of your X chromosomes is missing. -trisomy 21 - downs syndrome •It is the most common genetic condition in the United States. • •In the US, occurs in 1 of every 800 infants with many as 6,000 children born with Down syndrome each year. • •About 85% of infants survive one year and 50% of those will live longer than 50 years. • •3 genetic variations: -Trisomy 21 -Mosaicisim -Translocation -

Racial Disparities in IMR

•Very disturbing feature of the trends in IMR in US - disparity according to race •IMR for black Americans is more than double that for white Americans

Government Nutrition Programs

•WIC - provides vouchers for nutritious foods for pregnancy women, lactating mothers, children up to 5 - very effective •School Meals Program -Summer meal programs •Food Stamp Program •Food insecurity is still common in the U.S. -Food deserts

· Laboratory-based reporting

•a surveillance method in which the reports of cases come from clinical laboratory data (forgoing case review)

· Universal case reporting

•a surveillance system in which all cases of a disease are supposed to be reported